Healthcare Provider Details

I. General information

NPI: 1912967209
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29804 LAKE SHORE BLVD
WILLOWICK OH
44095-4611
US

IV. Provider business mailing address

PO BOX 781348
DETROIT MI
48278-1348
US

V. Phone/Fax

Practice location:
  • Phone: 440-585-3322
  • Fax: 440-585-1962
Mailing address:
  • Phone: 800-354-1895
  • Fax: 440-585-1962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BOB TRACZ
Title or Position: CFO
Credential:
Phone: 440-354-1953